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MRSA and the issue of infection control

Dr Karina O'Connell, Dr Sarah Bergin and Prof Martin Cormican look at meticillin-resistant S. aureus and examine the pros and cons of screening, isolation and cohorting in infection control

The term MRSA (meticillin-resistant Staphylococcus aureus) has been one of the most widely discussed healthcare topics in recent years. MRSA is frequently described as the major ‘superbug’ of our time. For patients and families, the mention of MRSA can cause a great deal of distress and this may be fuelled by anxiety and uncertainty among healthcare workers.

This article aims to present a balanced view of MRSA. The superbug is a very good example of the more general problems of healthcare-associated infection and of antibiotic resistance. A reasoned and informed approach to these problems is the approach that is most likely to be helpful to patients.

The most important take-home messages are:
1. Hand hygiene before and after every patient contact;
2. Do not use antibiotics if they are not needed;
3. Beware of experts and companies promoting ‘quick and easy solutions’ that have made MRSA go away in ‘St Elsewhere’;
4. The detection of MRSA in a swab is not an indication for treatment;
5. When treatment for mild MRSA infections is required, there are a variety of oral options available including doxycycline and co-trimoxazole;
6. There have been major changes in recent years in dosage and target blood levels for vancomycin.

Staphylococcus aureus
Staphylococcus aureus is a common bacterium present in the nose of about one in three people. It also colonises body surfaces and almost every individual has contact with S. aureus on a daily basis. It is spread to others and into the environment by contact with hands and/or fomites (inanimate objects that carry bacteria).

A person is more likely to develop an S. aureus infection if their natural defence mechanisms are impaired. A break in the skin (trauma, ingrown toe-nail, surgical incision or intravenous catheter, for example) is one of the most common risk factors associated with S. aureus infection. Diabetes mellitus, poor tissue perfusion and cytotoxic chemotherapy also increase risk of infection.

In the community setting, S. aureus is responsible mainly for skin and soft-tissue infections such as impetigo and cellulitis. In the hospital setting, it may be responsible for wound infections, peripheral and central-line infections and pneumonia.

MRSA: what is it exactly?
Penicillin was first discovered in 1928 and was introduced into clinical use in 1943. By the 1960s, many S. aureus isolates had become resistant to the early penicillins. This resistance is mediated by a β-lactamase enzyme called a penicillinase, which is capable of breaking down the β-lactam ring of penicillin. A new group of penicillinase-resistant penicillins (including meticillin and flucloxacillin), resistant to degradation by the staphylococcal penicillinase, were developed.

In England in 1961, a S. aureus isolate also resistant to the new penicillin, meticillin, was described. These variants were labelled meticillin-resistant S. aureus (MRSA). S. aureus isolates that are sensitive to meticillin are called meticillin-susceptible S. aureus (MSSA), although this term is less familiar outside of microbiology.

Resistance to meticillin is conferred by the mecA gene complex, which codes for an altered penicillin-binding protein (PBP2a). This altered protein has a lower affinity for the β-lactam group of antibiotics including the cephalosporins and carbapenems. MRSA has been detected in Ireland since 1971.

MRSA is a type of bacteria. It is not a diagnosis of infection. The distinction between MRSA colonisation and MRSA infection is very important. Differentiation is based primarily on clinical features and the type of specimen from which the MRSA was isolated.

Patients with chronic illnesses and frequent or extended periods of hospitalisation or residential care may be colonised with MRSA but suffer no harm. If a patient who is colonised develops an infection, the infection may or may not be related to the MRSA. In choosing treatment, it is important to consider the site and severity of infection.

Treatment of MRSA infection
If it is considered likely that MRSA is contributing to the infection, treatment options do not include penicillins or cephalosporins. However, MRSA-related infections are not necessarily more difficult to treat than MSSA infections provided an appropriate antibiotic is prescribed.

In all cases of S. aureus infection (MSSA and MRSA), a key principle is that if there is an abscess or tissue necrosis, surgical intervention has a critical role to play in management and if a venous catheter is implicated, it should be removed.

In systemic infections, glycopeptides (e.g. vancomycin) remain the antibiotics of first choice. There have been important changes in recent years in the use of vancomycin to treat S. aureus infection. The dose must be individualised based on bodyweight (15mg/kg). An initial large loading dose (25mg/kg) is often important in patients with life-threatening infection. It is essential to achieve vancomycin blood levels that are substantially higher than were considered desirable just a few years ago.

For less serious infections where oral antibiotics are an option, co-trimoxazole and doxycycline may be used in most cases. These antibiotics are particularly useful in the treatment of MRSA-infected leg ulcers in the community.

Newer agents including linezolid and daptomycin may be appropriate in certain specific circumstances but should be considered in consultation with a microbiologist or infectious disease physician.

Epidemiology of MRSA
MRSA can be divided into two main sub-groups: hospital/healthcare-associated MRSA (HAMRSA) and community-acquired MRSA (CAMRSA). They differ in molecular and clinical epidemiology. Risk factors for HAMRSA infection include prolonged hospitalisation, antibiotic use, admission to an intensive care unit, haemodialysis and proximity to others colonised or infected with MRSA.

CAMRSA is still relatively uncommon in Ireland. The typical picture is one of skin and soft-tissue infections in young, healthy individuals with no recent healthcare exposure. Community outbreaks have been described in several settings including sports teams, men who have sex with men and in prisons. Risk factors for CAMRSA include skin trauma and sharing equipment that is not cleaned or laundered between users. However, many patients have no identifiable risk factors. It is often not easy to judge if an MRSA isolate is HAMRSA or CAMRSA unless detailed typing studies are performed and this differentiation is not necessary for clinical management.

Screening for colonisation
Surveillance cultures may identify patients colonised with MRSA. Detection of MRSA carriage in specific patient groups may assist in minimising spread to other patients. It can assist in selection of appropriate antibiotic surgical prophylaxis and guide empiric treatment if infection develops.

A swab is taken from the anterior nares and body (groin and axilla). Sometimes examination of a throat swab is also recommended. In most laboratories in Ireland, the swabs are cultured on specific media and provisional positive results can be obtained from most positive patients within 24 hours of receipt in the laboratory.

A variety of molecular tests for rapid detection of MRSA are promoted to the professions and increasingly to the public and policy makers. These tests are generally very much more expensive than culture on selective agar plates.

Although an individual test can be done in hours, in practice specimens are generally batched for processing so that there is generally little practical advantage to be gained for the additional expense.

In Ireland, in the public health service, screening for detection of MRSA carriage is generally applied selectively to at-risk patients and in outbreak settings. Some private healthcare facilities may screen much more extensively, although it is not clear that this is of benefit to patients.

The extent to which screening should be performed is sometimes controversial. Various interest groups and healthcare professionals have called for more extensive screening citing practice in some countries with a low incidence of MRSA.

More extensive screening may be warranted in low-incidence countries; however it is simplistic to believe that extensive screening of itself is the explanation for the low incidence in countries such as the Netherlands or Norway. Countries with a low incidence of MRSA generally have a low incidence of other healthcare-associated antibiotic-resistant bacteria also. This reflects universal high standards of infection control practice and prudent antibiotic use over many decades.

In the context of a high incidence of MRSA, high antibiotic consumption, inadequate infrastructure, high bed-occupancy and staffing limitations in Ireland, there is little reason to believe that more extensive screening for MRSA would do any good. It would certainly involve significant laboratory costs. Some clinical laboratories may refuse to process requests for screening for MRSA carriage if it is not clear that there is a specific reason for the request.

Isolation and cohorting
In the acute hospital setting, patients colonised or infected with one of a number of transmissible organisms (including MRSA) are cared for in isolation or in a room/ward with other people who carry the same organism (cohorting).

When the patient goes home or to a long-stay facility, this level of precaution is not recommended and this can often cause confusion for patients and their families.

Individuals colonised with MRSA and surfaces or equipment that are contaminated from contact with MRSA can serve as a reservoir for the transmission of MRSA.

Transmission to other patients occurs most often by the contaminated hands of healthcare workers but equipment can also serve as a vehicle of transmission.

The use of isolation, contact precautions and dedicated equipment help to limit transmission. These measures are justified in the acute hospital setting where there are many other patients vulnerable to infection.

Decolonisation of patients can be attempted with topical agents such as mupirocin (applied to the nose) and chlorhexidine applied to skin and hair. Extensive use of these agents may be associated with emergence of resistance. Eradication of MRSA is very often unsuccessful and recolonisation may occur. In our experience, MRSA decolonisation is most likely to work when undertaken on a ward where the nursing staff have extensive experience of the application of the decolonisation protocols.

In the community setting, in nursing homes and in facilities for those with intellectual disability, isolation of those known to be colonised with MRSA is generally not recommended. This is because transmission is associated with a lower risk of serious infection in this setting, as people are generally less vulnerable to infection.

It is also important to recognise that the isolation measures that can be managed for a relatively short period in an acute hospital cannot be maintained indefinitely without detriment to the overall mental and physical health of the person.

Screening for MRSA and isolation of those colonised is not appropriate in these settings. The emphasis should be placed on maintaining high standards of personal and environmental hygiene, good nutrition and mobility and limiting the use of antibiotics.

Dr Karina O’Connell, Dr Sarah Bergin, and Prof Martin Cormican
Department of Microbiology, Galway University Hospitals & Medical School, NUI Galway.

Posted in on 10 September 2009
Tags: MRSA

Tagcloud

abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

MRSA and the issue of infection control

Dr Karina O'Connell, Dr Sarah Bergin and Prof Martin Cormican look at meticillin-resistant S. aureus and examine the pros and cons of screening, isolation and cohorting in infection control

The term MRSA (meticillin-resistant Staphylococcus aureus) has been one of the most widely discussed healthcare topics in recent years. MRSA is frequently described as the major ‘superbug’ of our time. For patients and families, the mention of MRSA can cause a great deal of distress and this may be fuelled by anxiety and uncertainty among healthcare workers.

This article aims to present a balanced view of MRSA. The superbug is a very good example of the more general problems of healthcare-associated infection and of antibiotic resistance. A reasoned and informed approach to these problems is the approach that is most likely to be helpful to patients.

The most important take-home messages are:
1. Hand hygiene before and after every patient contact;
2. Do not use antibiotics if they are not needed;
3. Beware of experts and companies promoting ‘quick and easy solutions’ that have made MRSA go away in ‘St Elsewhere’;
4. The detection of MRSA in a swab is not an indication for treatment;
5. When treatment for mild MRSA infections is required, there are a variety of oral options available including doxycycline and co-trimoxazole;
6. There have been major changes in recent years in dosage and target blood levels for vancomycin.

Staphylococcus aureus
Staphylococcus aureus is a common bacterium present in the nose of about one in three people. It also colonises body surfaces and almost every individual has contact with S. aureus on a daily basis. It is spread to others and into the environment by contact with hands and/or fomites (inanimate objects that carry bacteria).

A person is more likely to develop an S. aureus infection if their natural defence mechanisms are impaired. A break in the skin (trauma, ingrown toe-nail, surgical incision or intravenous catheter, for example) is one of the most common risk factors associated with S. aureus infection. Diabetes mellitus, poor tissue perfusion and cytotoxic chemotherapy also increase risk of infection.

In the community setting, S. aureus is responsible mainly for skin and soft-tissue infections such as impetigo and cellulitis. In the hospital setting, it may be responsible for wound infections, peripheral and central-line infections and pneumonia.

MRSA: what is it exactly?
Penicillin was first discovered in 1928 and was introduced into clinical use in 1943. By the 1960s, many S. aureus isolates had become resistant to the early penicillins. This resistance is mediated by a β-lactamase enzyme called a penicillinase, which is capable of breaking down the β-lactam ring of penicillin. A new group of penicillinase-resistant penicillins (including meticillin and flucloxacillin), resistant to degradation by the staphylococcal penicillinase, were developed.

In England in 1961, a S. aureus isolate also resistant to the new penicillin, meticillin, was described. These variants were labelled meticillin-resistant S. aureus (MRSA). S. aureus isolates that are sensitive to meticillin are called meticillin-susceptible S. aureus (MSSA), although this term is less familiar outside of microbiology.

Resistance to meticillin is conferred by the mecA gene complex, which codes for an altered penicillin-binding protein (PBP2a). This altered protein has a lower affinity for the β-lactam group of antibiotics including the cephalosporins and carbapenems. MRSA has been detected in Ireland since 1971.

MRSA is a type of bacteria. It is not a diagnosis of infection. The distinction between MRSA colonisation and MRSA infection is very important. Differentiation is based primarily on clinical features and the type of specimen from which the MRSA was isolated.

Patients with chronic illnesses and frequent or extended periods of hospitalisation or residential care may be colonised with MRSA but suffer no harm. If a patient who is colonised develops an infection, the infection may or may not be related to the MRSA. In choosing treatment, it is important to consider the site and severity of infection.

Treatment of MRSA infection
If it is considered likely that MRSA is contributing to the infection, treatment options do not include penicillins or cephalosporins. However, MRSA-related infections are not necessarily more difficult to treat than MSSA infections provided an appropriate antibiotic is prescribed.

In all cases of S. aureus infection (MSSA and MRSA), a key principle is that if there is an abscess or tissue necrosis, surgical intervention has a critical role to play in management and if a venous catheter is implicated, it should be removed.

In systemic infections, glycopeptides (e.g. vancomycin) remain the antibiotics of first choice. There have been important changes in recent years in the use of vancomycin to treat S. aureus infection. The dose must be individualised based on bodyweight (15mg/kg). An initial large loading dose (25mg/kg) is often important in patients with life-threatening infection. It is essential to achieve vancomycin blood levels that are substantially higher than were considered desirable just a few years ago.

For less serious infections where oral antibiotics are an option, co-trimoxazole and doxycycline may be used in most cases. These antibiotics are particularly useful in the treatment of MRSA-infected leg ulcers in the community.

Newer agents including linezolid and daptomycin may be appropriate in certain specific circumstances but should be considered in consultation with a microbiologist or infectious disease physician.

Epidemiology of MRSA
MRSA can be divided into two main sub-groups: hospital/healthcare-associated MRSA (HAMRSA) and community-acquired MRSA (CAMRSA). They differ in molecular and clinical epidemiology. Risk factors for HAMRSA infection include prolonged hospitalisation, antibiotic use, admission to an intensive care unit, haemodialysis and proximity to others colonised or infected with MRSA.

CAMRSA is still relatively uncommon in Ireland. The typical picture is one of skin and soft-tissue infections in young, healthy individuals with no recent healthcare exposure. Community outbreaks have been described in several settings including sports teams, men who have sex with men and in prisons. Risk factors for CAMRSA include skin trauma and sharing equipment that is not cleaned or laundered between users. However, many patients have no identifiable risk factors. It is often not easy to judge if an MRSA isolate is HAMRSA or CAMRSA unless detailed typing studies are performed and this differentiation is not necessary for clinical management.

Screening for colonisation
Surveillance cultures may identify patients colonised with MRSA. Detection of MRSA carriage in specific patient groups may assist in minimising spread to other patients. It can assist in selection of appropriate antibiotic surgical prophylaxis and guide empiric treatment if infection develops.

A swab is taken from the anterior nares and body (groin and axilla). Sometimes examination of a throat swab is also recommended. In most laboratories in Ireland, the swabs are cultured on specific media and provisional positive results can be obtained from most positive patients within 24 hours of receipt in the laboratory.

A variety of molecular tests for rapid detection of MRSA are promoted to the professions and increasingly to the public and policy makers. These tests are generally very much more expensive than culture on selective agar plates.

Although an individual test can be done in hours, in practice specimens are generally batched for processing so that there is generally little practical advantage to be gained for the additional expense.

In Ireland, in the public health service, screening for detection of MRSA carriage is generally applied selectively to at-risk patients and in outbreak settings. Some private healthcare facilities may screen much more extensively, although it is not clear that this is of benefit to patients.

The extent to which screening should be performed is sometimes controversial. Various interest groups and healthcare professionals have called for more extensive screening citing practice in some countries with a low incidence of MRSA.

More extensive screening may be warranted in low-incidence countries; however it is simplistic to believe that extensive screening of itself is the explanation for the low incidence in countries such as the Netherlands or Norway. Countries with a low incidence of MRSA generally have a low incidence of other healthcare-associated antibiotic-resistant bacteria also. This reflects universal high standards of infection control practice and prudent antibiotic use over many decades.

In the context of a high incidence of MRSA, high antibiotic consumption, inadequate infrastructure, high bed-occupancy and staffing limitations in Ireland, there is little reason to believe that more extensive screening for MRSA would do any good. It would certainly involve significant laboratory costs. Some clinical laboratories may refuse to process requests for screening for MRSA carriage if it is not clear that there is a specific reason for the request.

Isolation and cohorting
In the acute hospital setting, patients colonised or infected with one of a number of transmissible organisms (including MRSA) are cared for in isolation or in a room/ward with other people who carry the same organism (cohorting).

When the patient goes home or to a long-stay facility, this level of precaution is not recommended and this can often cause confusion for patients and their families.

Individuals colonised with MRSA and surfaces or equipment that are contaminated from contact with MRSA can serve as a reservoir for the transmission of MRSA.

Transmission to other patients occurs most often by the contaminated hands of healthcare workers but equipment can also serve as a vehicle of transmission.

The use of isolation, contact precautions and dedicated equipment help to limit transmission. These measures are justified in the acute hospital setting where there are many other patients vulnerable to infection.

Decolonisation of patients can be attempted with topical agents such as mupirocin (applied to the nose) and chlorhexidine applied to skin and hair. Extensive use of these agents may be associated with emergence of resistance. Eradication of MRSA is very often unsuccessful and recolonisation may occur. In our experience, MRSA decolonisation is most likely to work when undertaken on a ward where the nursing staff have extensive experience of the application of the decolonisation protocols.

In the community setting, in nursing homes and in facilities for those with intellectual disability, isolation of those known to be colonised with MRSA is generally not recommended. This is because transmission is associated with a lower risk of serious infection in this setting, as people are generally less vulnerable to infection.

It is also important to recognise that the isolation measures that can be managed for a relatively short period in an acute hospital cannot be maintained indefinitely without detriment to the overall mental and physical health of the person.

Screening for MRSA and isolation of those colonised is not appropriate in these settings. The emphasis should be placed on maintaining high standards of personal and environmental hygiene, good nutrition and mobility and limiting the use of antibiotics.

Dr Karina O’Connell, Dr Sarah Bergin, and Prof Martin Cormican
Department of Microbiology, Galway University Hospitals & Medical School, NUI Galway.

Posted in on 10 September 2009
Tags: MRSA